ࡱ > {` bjbjFF 4 , , > % T T T T T T T h & & & 8 & D ' < h X h T' j' " ' ' ' ' & ' ' W W W W W W W $ Y h ^\ ( +W T ~( ' ' ~( ~( +W T T ' ' HX J9 J9 J9 ~(
T ' T ' KR J9 ~( W J9 J9 M T T O ' H' dJz & 3 {N KR ^X 0 X N 6 ] 7 H ] , O O ] T OQ ' ' J9 ' ' ' ' ' +W +W 8 d ' ' ' X ~( ~( ~( ~( h h h l $ h h h l h h h T T T T T T P r i k l a d n o s t m o g u e g d a r i v a t e l j a o r g a n a , t k i v a i s t a n i c a s o b z i r o m n a p r i j e n o s i n f e k c i j a n a p r i m a t e l j a
S m i l j a K a l e n i , A n a B u d i m i r
K l i n i
k i b o l n i
k i c e n t a r Z a g r e b , R e f e r e n t n i c e n t a r z a b o l n i
k e i n f e k c i j e M i n i s t a r s t v a z d r a v s t v a i s o c i j a l n e s k r b i R e p u b l i k e H r v a t s k e , 1 0 0 0 0 Z a g r e b , K i ap a t i e v a 1 2
S a ~e t a k
P r e s a i v a n j e o r g a n a / t k i v a / s t a n i c a d o n o s i s a s o b o m r i z i k o d p r i j e n o s a i n f e k c i j e s d a r i v a t e l j a n a p r i m a t e l j a . I n f e k c i j e p r e n e s e n e n a t a j n a
i n m o g u b i t i v r l o t e ak e , s m r t o n o s n e , m o g u s e r a z v i t i u k r o n i
n e i n f e k c i j e z a k o j e n e m a o d g o v a r a j u e t e r a p i j e i l i i n f e k c i j e k o j e s e m o g u u s p j e an o l i j e
i t i a n t i m i k r o b n i m l i j e k o v i m a . P r i l i k o m p r o c j e n e m o g u e g d a r i v a t e l j a o r g a n a / t k i v a / s t a n i c a u v i j e k j e p o t r e b n o u z e t i u o b z i r i r i z i k o d p r i j e n o s a m i k r o o r g a n i z a m a i r a z v o j a i n f e k c i j e . R i z i k o d p r i j e n o s a i n f e k c i j e i s p i t u j e s e u z i m a n j e m a n a m n e z e i h e t e r o a n a m n e z e , p r e g l e d o m k l i n i
k e d o k u m e n t a c i j e , k l i n i
k o m e v a l u a c i j o m i p r i m j e n o m m i k r o b i o l o ak i h t e s t o v a . U r u t i n s k o j p r o c j e n i p r i k l a d n o s t i m o g u e g d a r i v a t e l j a o r g n a / t k i v a / s t a n i c a u p o t r e b l j a v a j u s e 1 ) s e r o l o ak i t e s t o v i ( A n t i - H I V 1 , 2 , H B s A g , A n t i - H B c , A n t i - H C V , a i V D R L / R P R , T P H A , A n t i - C M V , A n t i - C o x a c k i e B 1 d o B 6 i a n t i Q F p r i l i k o m d a r i v a n j a s r c a ) , 2 ) m o l e k u l a r n i t e s t o v i ( H B V , H I V , H C V ) i 3 ) k u l t u r a ( k r v i m o k r a a z a b a k t e r i o l o ak o t e s t i r a n j e).
Na osnovu prethodno navedenih metoda, darivatelj se kvalificira kao a) darivatelj prihvatljiv, b) darivatelj prihvatljiv uz individualni pristanak ili c) darivatelj apsolutno neprihvatljiv.
Suitability of potential organ, tissue and cells donor regarding the transmission of infection to recipient
S m i l j a K a l e n i , A n a B u d i m i r
C l i n i c a l h o s p i t a l c e n t r e Z a g r e b , R e f e r e n c e c e n t r e f o r h o s p i t a l i n f e c t i o n s M i n i s t r y o f h e a l t h a n d s o c i a l w e l l f a r e i n R e p u b l i c o f C r o a t i a
S u m m a r y
O r g a n / t i s s u e / c e l l s t r a n s p l a n t a t i o n c a r r i e s t h e r i s k o f i n f e c t i o n t r a n s f e r f r o m d o n o r to recipient. Consecutive infections can be severe, lethal, and proceed to chronic condition without possibillty of treating or an infection that is treatable with known antimicrobial drugs. Possible consequences and infection development should be taken into consideration during planning of the procedure. Risk of infectious disease transmission is estimated based upon patient`s history, evaluation of clinical documentation and aplication of microbiologic tests. In routine evaluation of organ/tissue/cells donor, number of tests are used: 1) serology (Anti-HIV 1,2, HBsAg, Anti-HBc, Anti-HCV, a i VDRL/RPR, TPHA , Anti-CMV, Anti-Coxackie B1 do B6 and Anti-Qfin heart transplantation), 2) molecular methods (HBV, HIV, HCV) and 3) blood and urine culture.
At present there are just few absolute exclusion criteria, and donor can be 1) absolutely suitable or 2) suitable with an individual approach (acceptance criteria may vary from team to team and may depend on recipient characteristics).
UVOD
P r e s a i v a n j e o r g a n a / t k i v a / s t a n i c a d a n a s p r e d s t a v l j a d i o s t a n d a r d n e z d r a v s t v e n e s k r b i u s v i m r a z v i j e n i m z e m l j a m a . O s i m n e p r o c j e n j i v e d o b r o b i t i , d o n o s i s a s o b o m r i z i k o d p r i j e n o s a i n f e k c i j e s d a r i v a t e l j a n a p r i m a t e l j a A D D I N E N . C I T E < E n d N o t e > < C i t e > < Y e a r > 2 0 04116<style face="normal" font="default" charset="238" size="100%">Guide to safety and quality assurance for organs, tissues and cells- Council of Europe </style><style face="normal" font="default" size="100%">
</style>(1). T a k o p r e n e s e n e i n f e k c i j e m o g u b i t i s m r t o n o s n e o d n o s n o t e ak e k r o n i
n e b e z d a n a s p o z n a t o g i z l j e
e n j a , a m o g u b i t i t a k v e d a i h s e d a n a an j i m a t i m i k r o b n i m l i j e k o v i m a m o ~e u s p j e an o l i j e
i t i ( t a b l i c a 1 . ) . S t o g a p r i l i k o m p r o c j e n e m o g u e g d a r i v a t e l j a o r g a n a / t k i v a / s t a n i c a u v i j e k t r e b a p r o c i j e n i t i r i z i k o d p r i j e n o s a i n f e k c i j e .
M E T O D E
R i z i k o d p r i j e n o s a i n f e k c i j e i s p i t u j e s e u t r i k o r a k a :
A n a m n e z a ( h e t e r o a n a m n e z a ) , p r e g l e d k l i n i
k e d o k u m e n t a c i j e
K l i n i
k a e v a l u a c i j a ( d e t a l j n i f i z i k a l n i p r e g l e d ~i v o g d a v a t e l j a , o d n o s n o p o k o j n i k a )
M i k r o b i o l o ak i t e s t o v i i h i s t o l o ak i n a l a z b i o p s i j e , u s l u
a j e v i m a k a d a t o n a l a ~u p r e t h o d n e r a z i n e p r e t r a g a .
1 . A n a m n e z a ( h e t e r o a n a m n e z a )
U a n a m n e z i o d n o s n o h e t e r o a n a m n e z i ( a a k o o v a p o t o n j a n i j e m o g u a , t r e b a j e z a m i j e n i t i d e t a l j a n p r e g l e d s v e u k u p n e m e d i c i n s k e d o k u m e n t a c i j e p o k o j n i k a ) t r e b a p r o v j e r i t i m o g u e s i m p t o m e s u s t a v n e i n f e k c i j e i l i i n f e k c i j e o d r e e n o g o r g a n a i l i b o l e s t i n e p o z n a t e e t i o l o g i j e u b l i s k o j p r o al o s t i , n a p o s e u z r o k s m r t i u p o k o j n i k a ; m o g u e r i z i
n o p o n a aa n j e ; p u t o v a n j a u t r o p s k e k r a j e v e ( m o g u p r i j e n o s m a l a r i j e i t r i p a n o s o m i j a z e ) , n e d a v n a i m u n i z a c i j a ~i v i m v a k c i n a m a , m o g u e p r i m a n j e t r a n s f u z i j e k r v i i l i t r a n s p l a n t a t a u p o s l j e d n j i h 1 2 m j e s e c i , r i z i k o d p r i o n s k i h b l e s t i ( b i l o o b i t e l j s k i h i l i i a t r o g e n i h ) , t e d r u g e r e l e v a n t n e p o d a t k e ( 2 ) . A k o s e n e m o g u d o b i t i a n a m n e s t i
k i p o d a c i d a b i s e d a r i v a t e l j s m a t r a o p r i h v a t l j i v i m , p o t r e b n o j e u
i n i t i d o d a t n e d a l j n j e p r e t r a g e u c i l j u o t k r i v a n j a m o g u e g p o s t o j a n j a j e d n o g o d k r i t e r i j a a p s o l u t n e n e p o d o b n o s t i ( 2 ) .
2 . K l i n i
k a e v a l u a c i j a
P r i l i k o m k l i n i
k e p r o c j e n e d a r i v a t e l j a t r e b a p r e g l e d a t i u p o t p u n o s t i ( k o d p o k o j n i k a m o ~e t o b i t i p r e m o r t a l n i i l i p o s t m o r t a l n i p r e g l e d ) , u p r v o m r e d u d a s e p o t r a ~i d o k a z r i z i
n o g p o n a aa n j a ( n o v i p i e r c i n g , u b o d i i g l e u n a r k o m a n a ) , z a t i m n e r a z j a an j e n a ~u t i c a , i n f e k c i j a k o ~e i l i t r a u m a ; o ~i l j c i o d m o g u i h m e d i c i n s k i h z a h v a t a , l e z i j e k o ~e i l i v i d l j i v i h s l u z n i c a , g e n e r a l i z i r a n o p o v e a n j e l i m f n i h
v o r o v a . T r e b a n o t i r a t i b r o j d a n a p r o v e d e n i h u j e d i n i c i i n t e n z i v n o g l i j e
e n j a .
3 . M i k r o b i o l o ak i t e s t o v i
N e k e o d i n f e k c i j a i z t a b l i c e 1 . n e m o g u s e d a n a s d i j a g n o s t i c i r a t i b e z b i o p s i j e m o z g a o d n o s n o a u t o p s i j e ( C J D , v C J D ) , a l i s e r i z i k z a p r i s u t n o s t t i h b o l e s t i p r o c j e n j u j e n a o s n o v u a n a m n e s t i
k i h p o d a t a k a o u z i m a n j u h o r m o n a h i p o f i z e , n e u r o k i r u r ak i m z a h v a t i m a u z k o r i at e n j e p r e s a t k a d u r e m a e r , p r i s u t n o s t i s i m p t o m a p r o g r e s i v n e d e m e n c i j e i l i d e g e n e r a t i v n e n e u r o l o ak e b o l e s t i n e p o z n a t a u z r o k a , p o z i t i v n o j o b i t e l j s k o j a n a m n e z i k a d j e r i j e
o n e v e d e n i m b o l e s t i m a . V e l i k i d i o i n f e k c i j a u z r o k o v a n i m u z r o
n i c i m a i z t a b l i c e 1 . d i j a g n o s t i c i r a j u z a ~i v o t a b o l e s n i k a s p e c i j a l n i m t e s t o v i m a k o j i n i s u r u t i n s k i d o s t u p n i ( r a b i e s ) , d o k s e d r u g e m o g u d i j a g n o s t i c i r a t i d o s t u p n i m t e s t o v i m a v i s o k e o s j e t l j i v o s t i i s p e c i f i
n o s t i , s v i s o k i m n e g a t i v n i m i p o z i t i v n i m p r e d i k t i v n i m v r i j e d n o s t i m a ( 1 ) . T i s e t e s t o v i s t o g a u p o t r e b l j a v a j u u r u t i n s k o j p r o c j e n i p r i k l a d n o s t i m o g u e g d a r i v a t e l j a o r g a n a / t k i v a / s t a n i c a s o b z i r o m n a r i z i k p r i j e n o s a i n f e k c i j a n a p r i m a t e l j e .
I n f e k c i j a s e u m o g u e g d a r i v a t e l j a m o ~e i s k l j u
i t i s e r o l o ak i ( v i r u s i , b a k t e r i j e , p a r a z i t i ) , m o l e k u l a r n i m t e h n i k a m a ( v i r u s i ) , t e k u l t u r o m ( b a k t e r i j e , g l j i v e ) .
a ) S e r o l o ak i t e s t o v i
U s v i j e t u p o s t o j e r a z l i
i t e s h e m e o b v e z n i h s e r o l o ak i h t e s t o v a , o v i s n o s j e d n e s t r a n e o m o g u n o s t i m a , a s d r u g e s t r a n e o s l a g a n j u d a r i v a t e l j a - p r i m a t e l j a s o b z i r o m n a n e k i p o s e b n i o r g a n . S v e s h e m e k a o m i n i m a l n e t e s t o v e n a v o d e s l j e d e e t e s t o v e ( 2 ) :
1 . A n t i - H I V 1 , 2
2 . H B s A g , A n t i - H B c
3 . A n t i - H C V
U n e k i m j e s h e m a m a ( i u R e p u b l i c i H r v a t s k o j ) ( 2 ) m e u o b v e z n i m t e s t o v i m a d i j a g n o s t i k a s i f i l i s a ( V D R L / R P R i T P H A ) . N a d a l j e ,
e s t o s e u s h e m a m a n a l a z e i A n t i - C M V , A n t i - E B V i A n t i - T o x o p l a s m a t e s t o v i . Z a o d r e e n e o r g a n e d o d a j u s e j o a n e k i t e s t o v i ( A n t i - C o x s a c k i e B 1 d o B 6 i A n t i - Q F p r i l i k o m d a r i v a n j a s r c a ) .
U p o d r u
j i m a s v i s o k o m p r e v a l e n c i j o m H T L V I i I I , z a h t i j e v a s e i t e s t n a A n t i - H T L V I i I I ( K a r i p s k o o t o
j e , A f r i k a , J u g o z a p a d n i J a p a n ) .
S e r o l o ak i t e s t o v i s u b r z i t e s t o v i i m o g u s e z a v r ai t i u v r e m e n u d o 4 s a t a o d p r i m a n j a k r v i u l a b o r a t o r i j u . O s n o v n a p r a v i l a k o j i h b i s e t r e b a l o p r i d r ~a v a t i p r i l i k o m s e r o l o ak o g t e s t i r a n j a m o g u i h d a r i v a t e l j a o r g a n a / t k i v a / s tanica, jesu:
1. Provodi ga laboratorij s iskustvom. U Republici Hrvatskoj ne postoji zasada laboratorij akreditiran za tu svrhu, no postoje laboratoriji s vanjskom kontrolom kvalitete, te bi postojanje vanjske kontrole kvalitete za takav laboratorij trebao biti minimalni zahtjev.
2 . T e s t o v i m o r a j u b i t i n a j n o v i j e r e g i s t r i r a n e g e n e r a c i j e , at o j a m
i n a j v e u p o s t o j e u o s j e t l j i v o s t i s p e c i f i
n o s t .
3 . N a t e s t i r a n j e s e aa l j e s a m o p u n a k r v , s e r u m i l i p l a z m a , a n e d r u g e t j e l e s n e t e k u i n e n i t i i z l u
e v i n e . K r v s e k o d p o k o j n i k a - p o t e n c i j a l n i h d a r i v a t e l j a u z i m a n a j k a s n i j e 2 4 s a t a n a k o n s m r t i . I d e a l n o j e a k o p o s t o j i u z o r a k k o j i j e u z e t u d r u g e s v r h e p r i j e s m r t i i p o h r a n j e n . U ~i v i h d a r i v a t e l j a i d e a l n o j e k r v u z e t i u v r i j e m e d a r i v a n j a ( o s i m z a a l o g e n u k o at a n u s r ~ i m a t i
n e s t a n i c e , k a d a s e k r v u z i m a u n u t a r 3 0 d a n a p r i j e d o n a c i j e ) , a m o g u e j e u z e t i j e i d o 7 d a n a n a k o n d a r i v a n j a ( 3 , 4 ) .
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